Back pain - Practical Bodywork

On The Bleeding Edge of Science

Twenty years ago, a friend of mine stopped being able to walk.

It happened intermittently. She’d be fine for a few weeks or months, then collapse. She had intense pelvic pain that doctors couldn’t find a reason for. Some thought she was faking it and sent her to the psych ward, or gave her a catheter without anesthetic “to teach her a lesson.”

No doctor, as far as I know, asked her if she had a history of childhood abuse.

Then came the CDC’s Adverse Childhood Experience study (ACE), a study of 17,000 adults which correlated long-term health outcomes with childhood trauma. It suggested that certain experiences are risk factors for leading causes of illness and death–as well as poor quality of life, including idiopathic pain. Chronic, high-intensity stress in childhood, it seems, can re-engineer your nervous system, and not for the better.

In my bodywork practice, my biggest source of fascination and frustration is “mystery pain,” often accompanied by “mystery fatigue.” I can get a little obsessed. In trying to solve the problem of why a client is in pain, exhausted, dizzy, depressed, anxious, can’t walk properly, or gets “pins and needles” for no apparent reason, I’ve researched not only musculoskeletal problems, such as injuries, arthritis, disc disease, spinal stenosis and spondylitis, but also adrenal fatigue, chronic Lyme, and any nervous system illness we have a name for, including every type of sclerosis that they thought my friend had, and then ruled out.

And I keep going back to the ACE study. All the TED talks and spin-off studies and New Health Initiatives focus on prevention, which is splendid. But what about people whose nervous systems are already kerflucked? Is there any way to help them?

Answer: I don’t know.

We know the nervous system is plastic; it can be rewired, to a certain extent. We know that PTSD is treatable. Could we develop a protocol in cases of idiopathic pain and fatigue syndrome, otherwise known as Nobody Knows Why I’m Kerflucked?

Because the danger in addressing an undiagnosable problem in a holistic way, is that you may be attacking it at the wrong level. You can’t heal a broken leg by changing your mindset. Too many holistic practitioners make claims that aren’t backed up by research. As a colleague noted when she said, “I don’t know any other massage therapists quite like you.”

So I keep asking questions. I keep reading research. And I keep up my attempts to hack into your nervous system, and tell it there’s no cause for alarm.

The Problems That Can’t Be Solved

My brother-in-law, Leif Weaver, passed away on November 14, after an eighteen-month battle with aggressive mantle-cell lymphoma. I loved him a whole lot.

His memorial was filled with friends and family who were just as broken-hearted, many of whom had flown cross-country on a few hours’ notice to say goodbye. We spent the evening swapping hilarious Leif stories, hugging one another and openly weeping. Love was everywhere.

During the course of his illness, I and others close to him experienced a host of sympathetic, stress-induced symptoms. Back spasms, sciatic pain, the onset of MS. Medical treatment could only take us so far. The body and mind have their own methods and timeline for processing trauma, physical and emotional.

In my bodywork practice, I call myself a creative problem-solver. The truth is, a lot of problems can’t be solved. While going through Leif’s illness and passing, I’ve shared the pain of many of my clients who are dealing with similar situations. When someone you love is seriously ill, your mind has to do something with the inevitable feelings of fear and helplessness; often this manifests as intractable pain. As both patient and therapist, sometimes all I can do is acknowledge the pain, treat it with the skills at my disposal, and wait for it to pass.

It always does.

The Body Remembers

I am so thankful for the treatment that I received!!! I walked in the office a horrific mess, and Stephanie showed her concern and learned what the issue was that I was having and in four short weeks, my body responded to the gentle, yet firm work that she was putting into it. My recovery was felt within the first visit, and continuously improved with each visit.

—Camille A., on Yelp.com

More than a year ago, Camille was struck by a car while she was crossing the street on foot. Most of the impact was sustained by her left hip. She underwent a plethora of treatments at the time, and reduced her pain to almost nil. Then one afternoon she ‘turned her head the wrong way,’ and it all started up, worse than before.

When Camille first came to me, she was stooped at nearly a 60 degree angle. She couldn’t lie prone with her back straight; she couldn’t lie on her back at all. She was in continuous pain in all positions. and I was concerned that she had problems outside of the scope of my ability to treat.

But she’d been to chiropractors, MDs and physical therapists, and the most recent chiropractor recommended massage. So I worked on her in the most non-invasive manner possible, adjusting positions to compensate for her pain. The entire left side of her body was in an extreme state of spasm, particularly her left piriformis and adductor muscles.

After her first session with me, she felt some relief, and decided to book a Crisis Intervention package. I didn’t find evidence of active trauma, such as inflammation, a slipped disc or scar tissue, so I simply encouraged her spasming muscles to calm down.

And ultimately, this seemed to be all that was required. By the end of her treatment, she was moving normally, the spasming had ceased, and she was nearly pain-free.

As I told Camille (and as I wrote to her lawyer, at her request), my belief is that she was suffering from post-traumatic stress. Memory of trauma is actually stored in our cells until it can be safely released; sometimes the smallest twitch is all that is required to re-activate the signal.

What does this mean, for clients and for therapists? Well, the good news is that it’s not permanent. Over time, and with patient engagement, the tissues will literally ‘release’ both the memories and the pain.

But at the same time, it’s important to remember that not all pain can be resolved by actively ‘fixing’ a problem. Some treatments, such as drugs and surgery, can make it worse. All too often, people take a hammer to a problem that merely needs a bit of unwinding.

Why Are Rehab Centers So Ugly? (Part II)

I’ve been a professional fine artist for half my life. The aesthetics of my surroundings are as important to me as the quality of the air I breathe. A vast empty wall in my living space makes me feel as though I am in prison. I can make a case for the notion that kitsch is morally wrong.

But is this just about my personal quirks? Do the aesthetics of surroundings really matter enough that hospitals, rehab centers and doctor’s offices ought to be concerned about them?

It has been established that the environment of psychiatric hospitals plays a significant role in both patient and staff functioning. The recommendations read like a manual for holistic health–natural or full-spectrum light, access to nature, calming colors, comfortable furniture, and access to private spaces. Artwork (soothing, not exciting) is recommended.

So it would seem that the converse–bright or fluorescent lights, bare white walls, ‘highly reverberent spaces’ (a psychiatric hospital no-no), and windowless rooms might be stressful for patients and staff alike. When we are in stressful environments, our bodies produce stress hormones which inhibit immune functioning.

Physician Heal Thyself

Piriformis_muscle

Image via Wikipedia

–guest post by Sujatha Ramakrishna, M.D.

Having a family full of doctors can be such a mixed blessing. Most physicians are aware of the pitfalls of being related to someone who knows way too much about every little ache or cough.

When I was a fourth-year medical student interviewing for residency positions in psychiatry, I met up with the department chair at UT Southwestern in Dallas, whose wife was also a physician. I guess he must have gotten bored with the usual interview questions, or perhaps he took one look at my transcript and decided there was no way was he accepting me into his program, because the discussion took a personal turn.

He asked me what it was like having two physicians for parents, and hinted that certain issues had arisen over the years with his own children. My response was simply, “Well, when I was a kid, and I got sick, they either didn’t care at all … or they totally freaked out.” He just about died laughing at that one. It must have sounded incredibly familiar to him. Perhaps that answer meant that I would have gotten accepted into his program after all.

Now I am a grown-up shrink, and I still have a family full of doctors who provide ample advice, both solicited and unsolicited, for every ailment imaginable.

A few months ago, I got up quickly after sitting in an awkward position on the edge of my couch, and I thought that my right leg was asleep. Well, walking it off, of course, was the solution. Only … whoops! I had foot drop. For those of you who don’t know, this means that when you try to walk your toes drag the ground. Flashback to those med school classes, trying to remember what that meant. Was I having a stroke? A compressed nerve? Hysterical paralysis?

Med school was 20 years ago, as was my last neurology rotation, so of course I had no idea. But I knew that Google would save me … hmm … “damage to the peroneal nerve.” Ok, that sounded reasonable.

But wait, it wasn’t so simple. I also started having twinges under my right seat bone, with radiating pain down the back of my thigh and around to the front of my lower leg. Not good. I had to cancel a trip to Texas, because I had been planning to drive but couldn’t sit for that long.

That’s when all hell broke loose.

My mom the family practitioner called me up, and suggested all sorts of narcotics and muscle relaxants that I could take. She said that if I came down to Texas my sister the radiologist would get me a free MRI. My cousin the orthopedic surgeon asked me if I had back pain, and wanted to know the positional nature of the symptoms.

My aunt the pathologist told me that the real problem was that I needed to acquire more padding on my ass, and suggested having a mojito to get that process started ASAP. As a side note here, one of the really wonderful things about belonging to an Indian family is that you get updates on how much weight you have gained or lost every time you see them, even if the scale says that you haven’t gone up or down 2-3 pounds in the last five years.

My uncle the vascular surgeon, after having a few scotches at that same gathering, started off with a recommendation for a nerve removal, assuring me that yes he had done neurosurgery rotations back in the 1970s (!) and finished with the brilliant idea that a total leg amputation would be a more permanent solution and also earn him more money.

My father the emergency room physician had the most practical advice of all, which was simply, “Don’t drive to Texas.” Words to live by.

Fortunately, another cousin of mine and her husband are physical therapists. I showed them where it hurt, and they immediately said, “Aha! Piriformis!” I said, “What???” We either hadn’t learned about that one in anatomy class, or I had forgotten. More likely than not the latter.

Basically, the problem was a tight muscle which was compressing the nerve. They showed me a stretch that would relieve the tightness — sitting on the floor with my knees bent, crossing the right leg over the left, and using my left hand to pull my right knee towards my left shoulder.

Soon the party at my cousin’s house turned into a mini-yoga class for everyone, which was hilarious but also more therapeutic than any advice that I had received from any of the physicians. I did the stretches that they showed me every morning, and I haven’t had a problem with that nerve since then.

Obviously I am lucky to have such a caring family, and their intentions were nothing but the best. But this story is a great example of how maybe we doctors are too quick to turn to pills, diagnostic equipment, and the knife in every situation. When those things are not indicated, we have few other resources to fall back on.

Back in the old days, doctors didn’t have all the fancy tests that we have now, so they had to spend a lot more time listening to and observing the patient in order to make their diagnosis. You might even say that the close personal relationships which they had with their patients were their best diagnostic and therapeutic tools. We could all use a lot more of that these days.

Massaging the Violin

Science has finally come around to studying massage, sort of:

Massages Ease Low Back Pain – NYTimes.com.

…Each of the massage groups received 10 weeks of treatment, and at the end of that period, all three groups had some improvement, as measured by their answers to 23 questions about performing routine activities without help — for example, climbing stairs without using a handrail or getting out of an easy chair by themselves. They were also asked to rate the degree of their back pain symptoms on a 10-point scale.

Those who received massage scored significantly better on both symptom and function tests, and they spent less time in bed, used less medicine and were more satisfied with their current level of back pain.

As much as this supports my bias, I have a quibble with studies which look at ‘massage’ as a generic unit, as though it were the functional equivalent of taking a pill. All massages are not created equal, just as every body is unique. There’s as much difference between a rub-down by rote and a master massage as there is between a C-major scale and an encore by Itzak Perlman.

Recently I got a Swedish massage at a local spa, courtesy of Groupon. It was a screamingly frustrating experience. The therapist applied some standard moves to the surface of my skin, regardless of whether the muscles underneath were tense, knotted, spasming, or comparatively relaxed. Areas which needed little attention got far too much of it (why spend 10 minutes frictioning the iliac crest? Because it’s there?) whereas the problem spots felt all the worse for having been teased. The aggregate effect was to bring all my imbalances into sharp relief, and leave me feeling desperate for another massage.

This may be an effective marketing tactic, but it sells massage therapy terribly short. A good massage therapist will be able to feel those knots, adhesions and spasms, and perform any number of targeted actions to release them. As I havewritten at length, the area where a client hurts may not be the actual source of the problem; lower back pain can often be traced to restrictions in the legs, hips, chest and even the feet. Although it’s difficult to figure out where these restrictions might be from an initial assessment, it’s pretty obvious once you get your hands on them.

The article goes on to state, “It is unclear how massage eases back pain, but the researchers suggest it may stimulate tissue locally or cause a more generalized central nervous system response.” Hello? How much more vague can you get?Obviously massage is ‘stimulating tissue locally’ and causing a ‘generalized central nervous system response’ (it’s frequently called ‘sleep,’) but if the researchers can’t pinpoint anything more specific than that, there’s a communication breakdown somewhere. Either they’re not asking the massage therapists any questions, or the therapists themselves aren’t clear about what they’re doing.